The essential feature of this disorder is recurrent obsessions or compulsions sufficiently severe to cause marked distress, be time-consuming or significantly interfere with the person's normal routine, occupational functioning or usual social activities or relationships with others.
Obsessions are persistent ideas, thoughts, impulses or images that are experienced, at least initially, as intrusive and senseless -- for example, a parent having repeated impulses to kill a loved child or a religious person having recurrent blasphemous thoughts. The person attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action. The person recognizes that the obsessions are the product of his or her own mind and are not imposed from without (as in the delusion of thought insertion).
The most common obsessions are repetitive thoughts of violence (e.g., killing one's child), contamination (e.g., becoming infected by shaking hands), and doubt (e.g., repeatedly wondering whether one has performed some act, such as having hurt someone in a traffic accident).
Compulsions are repetitive, purposeful and intentional behaviors that are performed in response to an obsession, according to certain rules or in a stereotyped fashion. The behavior is designed to neutralize or to prevent discomfort or some dreaded event or situation. However, either the activity is not connected in a realistic way with what it is designed to neutralize or prevent or it is clearly excessive. The act is performed with a sense of subjective compulsion that is coupled with a desire to resist the compulsion (at least initially). The person recognizes that his or her behavior is excessive or unreasonable (this may not be true for young children and may no longer be true for people whose obsessions have evolved into overvalued ideas) and does not derive pleasure from carrying out the activity, although it provides a release of tension. The most common compulsions involve hand-washing, counting, checking and touching.
When the person attempts to resist a compulsion, there is a sense of mounting tension that can be immediately relieved by yielding to the compulsion. In the course of the illness, after repeated failure at resisting the compulsions, the person may give in to them and no longer experience a desire to resist them.
Associated features. Depression and anxiety are common. Frequently there is phobic avoidance of situations that involve the content of the obsessions, such as dirt or contamination. For example, a person with obsessions about dirt may avoid public restrooms; a person with obsessions about contamination may avoid shaking hands with strangers.
Age at onset. Although the disorder usually begins in adolescence or early adulthood, it may begin in childhood.
Course. The course is usually chronic, with waxing and waning of symptoms.
Impairment. Impairment is often moderate or severe. In some cases acting according to the compulsions may become the major life activity.
Complications. Complications include Major Depression and the abuse of alcohol and anxiolytics.
Predisposing factors. No information.
Prevalence. Although the disorder was previously thought to be relatively rare in the general population, recent community studies indicate that mild forms of the disorder may be relatively common.
Sex ratio. This disorder is equally common in males and in females.
Differential diagnosis. Some activities, such as eating (e.g., Eating Disorders), sexual behavior (e.g., Paraphilias), gambling (e.g., Pathological Gambling) or drinking (e.g., Alcohol Dependence or Abuse), when engaged in excessively may be referred to as "compulsive." However, the activities are not true compulsions because the person derives pleasure from the particular activity and may wish to resist it only because of its secondary deleterious consequences.
In a Major Depressive Episode, obsessive brooding about potentially unpleasant circumstances or about possible alternative actions is common. However, these symptoms lack the quality of being experienced as senseless because the person generally regards the ideation as meaningful, although possibly excessive. Therefore, these are not true obsessions.
In some cases of Obsessive Compulsive Disorder, the obsession becomes an overvalued idea, such as the almost unshakable belief that one is contaminating other people. Such overvalued ideas may be bizarre and suggest Schizophrenia. However, the person with Obsessive Compulsive Disorder who has an overvalued idea can usually, after considerable discussion, acknowledge the possibility that his or her belief may be unfounded. In contrast, the person with a true delusion usually has a fixed conviction that cannot be shaken.
In Schizophrenia, stereotyped behavior is common, but it is usually due to delusions rather than to true compulsions. However, in some cases of Obsessive Compulsive Disorder, there may be bizarre delusions and other symptoms unrelated to the disorder that justify the additional diagnosis of Schizophrenia.
In some people with Tourette's Disorder, an associated diagnosis is Obsessive Compulsive Disorder.
| Diagnostic criteria for 300.30 Obsessive Compulsive Disorder |
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